The Pharmaceutical Journal Vol 264 No 7092 p603
April 15, 2000 Forum

Pharmaceutical care and concordance

Let us examine two philosophies of practice which have emerged in the past decade. What is interesting is that both philosophies are value based. I will start with the dominant value statement to have come out of pharmacy in the past quarter century, that of pharmaccutical care. This was proposed by Hepler and Strand in 1990, and has swept across pharmacy throughout the world. Their goal was worthy, to rally pharmacy round a philosophy that was value based and put the patient at its centre, rather than supply of the drug, and to a great extent they have succeeded in this in the USA. However, the concept is flawed in several ways, and, in particular, I wish to concentrate on the philosophy of right contained in their philosophy of our profession. The key phrase is that "pharmaceutical care is provided for the direct benefit of the patient" and the pharmacist is required to help achieve the therapeutic goals of the patient and avoid drug related harm. Indeed, the whole rationale to the [Hepler and Strand] paper is the avoidance of harm, nonmaleficence. My interpretation of this, given the rest of their paper, is that this is a duty based philosophy of practice. There is no mention of goal based issues, in which the patient may not get the ideal therapy because of the general good that will come from them receiving some other treatment. Now, this is certainly part of the role a professional should play - using their expert knowledge base to respond to a client's needs. However is this sufficient as a complete philosophy? The answer is that it is not. Looking back to Dworkin's typology of theories of rights we see that this is a duty based philosophy, and. . . we know that it will not be sufficient for all circumstances. For example, if a drug had a low chance of success yet is very expensive, should the NHS pay for it? Or should an antibiotic be given when a throat infection is of unknown cause, but probably viral?

Nick Barber: inadequate theories

This is probably why, although the term pharmaceutical care is now commonly used throughout the world, its definition is often changed. In Europe, for example, some goal based reference to societal good is usually built in to it.
The interpretation of pharmaceutical care that I have given is open to challenge. However, it is the one that commonly seems to be held in the UK. Even if this interpretation is wrong, it implies that the authors were not aware of the different types of moral theories, or they would have sketched out their theory against that background. Pharmaceutical care has been developed by Cipolle, Strand and Morley in their book in 1998. Here there is some more explicit recognition of the rights based morality. It includes reference to the individual's rights, and a recognition of issues such as patient's concerns and expectations. However, it seems that there is still a lack of recognition of goal based morality, and it is not clear how they would deal with conflicts between the rights based and duty based elements, for example, if a patient wanted to die by euthanasia. Again, one thinks that, while there is a clear recognition of some philosophical issues, such as the concept of care, a greater understanding of philosophy would have helped define their concept more clearly, and perhaps lead to its review.
I think a similar criticism can be made of the concept of concordance which, as originally formulated in 1997, is a rights based philosophy. It is an attempt to define an ideal relationship between the prescriber and patient, and was stimulated by work funded by the Royal Pharmaceutical Society and MSD to investigate non-adherence - patients not taking their medicines as prescribed. It refers to a use of medicines "compatible with what the patient desires", and also talks of the doctor and patient having "an alliance in which the most important determinations are. . . those made by the patient". The philosophy underpinning concordance would, therefore, seem to be rights based. But does this seem right? Should it be possible for our scientific knowledge of medicines to be overridden by alternative views of them? For public money to be spent on decisions made in this way? It does not seem so to me. Concordance does not seem a realistic philosophy because, being based on a single system of what is right, it runs into trouble, leading to situations most of us would consider wrong.
It may be that concordance is painted against a background of assumed values; however this is of no help, as we all may assume different background value systems. Do the proponents of concordance think, for example, that a drug should be prescribed outside its product licence if the patient so wishes? If so, are there special circumstances that would be attached, and what are they? I suspect such a rights based philosophy can only exist within goal and duty based frameworks, such as the Medicines Act.
I understand that the concept of concordance is being developed, and that this rights based element of it may change; however it illustrates my point in that it is a theory based on a single system of rights. A greater awareness of values systems may have led to a different formulation of the original statement.
Both pharmaceutical care and concordance are based on single moral theories. On the surface these give simplicity; however they are likely to be inadequate when they conflict with other types of moral imperatives. It may be better to use a mixture of theories, accept that there will be difficulties when they conflict, and look for a way of helping people in these circumstances.

Developing pharmacy values

At the end of his lecture, Professor Barber drew attention to a paper on the values of pharmacy, which is to be published by the Royal Pharmaceutical Society shortly. He said that the paper, which he had drawn up with Dr Alan Cribb (deputy director, centre for public policy research, King's College London), started by introducing the pressing needs to understand values which went beyond the professional relationship with patients, and encompassed a greater understanding of pharmacists and the environment in which the profession practised. Professor Barber said that the paper stated a number of reasons why discussing medicines responsibly whilst ignoring questions about values and society was impossible. These included: health policy dilemmas, pluralism, accountability, new ways of working and public involvement.
The report went on to say that: "It is no longer acceptable for health professionals, including pharmacists, to assume that what they do is always for the good, or that providing they have good technical expertise and obey the law they will ‘do the right thing'. It is essential to recognise that pharmacy is a ‘values-based' as well as knowledge-based profession." A plan of education and research to develop values literacy was also proposed in the paper.